Management of Poisoned Patients: Implementing a Blended Toxicology Curriculum for Emergency Medicine Residents

Audience This curriculum is appropriate for emergency medicine residents PGY 1-3 as a toxicology curriculum. Length of Curriculum The intent is to run this curriculum over one week. Introduction Toxicology is an important part of the emergency medicine (EM) curriculum and defined in the Council of Residency Directors (CORD) 2019 Model of Clinical Practice of Emergency Medicine as a key area of core content expected to be mastered by graduating EM seniors.1 Unfortunately, programs may not have time in their schedules for a dedicated toxicology curriculum, and residents may not have time to learn this important subject outside of conference didactics. Many emergency medicine programs have mandatory toxicology rotations, as many as 66% according to a 2018 study, with an additional 22% of EM programs offering an elective.2 At our institution, we have limited toxicology faculty available for instruction, and until now have only been able to incorporate occasional lectures into regular conference didactics, prompting our development of a new approach. Developing an asynchronous curriculum allows more dedicated time to study toxicology for our learners and allows greater flexibility for our limited toxicology faculty to teach during a synchronous component. Several asynchronous toxicology curricula have been developed previously.3,4 There have also been several novel synchronous toxicology curricular innovations for introduction during regular conference didactics.5,6 While some learners can benefit from asynchronous learning alone, it has been shown that having synchronous components in distance learning can be very important for improving learning experience and improving deep understanding rather than surface learning.7 Here we propose a one-week, blended asynchronous and synchronous rotation in toxicology that aims to give learners a foundation in important core toxicological concepts that they can implement on shift in the Emergency Department. Educational Goals The goal of this curriculum is to introduce EM residents to core toxicology concepts and to reinforce toxicology principles through a multimodal approach that leads to increased confidence in the management of poisoned patients on shift. Educational Methods The educational strategies used in this curriculum include: 1) Online asynchronous modules for each day of the week consisting of free open access medical education (FOAMed) articles, instruction on core topics, and daily quizzes. The content was created, organized, and published utilizing Articulate Rise 360 8 as a learning management system (LMS) but could easily be adapted to other LMS platforms, such as Google Classroom. The majority of educational content used to build the modules was based on Rosen’s Emergency Medicine Concepts and Clinical Practice. (5th editions). 2) A virtual simulation session reviewing toxicology cases with a faculty member. Cases were initially oral boards style cases but were later adapted to independent learning sessions utilizing pre-made Full-Code 9 scenarios. This could likely be adapted to other platforms such as in-person simulation for institutions without Full Code subscriptions. 3) A virtual discussion and question & answer board review session with a staff toxicologist. Research Methods Following completion of the course, residents were encouraged to fill out a survey developed by the writer of the course designed to assess their thoughts about the course, their confidence in recognizing toxidromes as well as their comfort in the medical management of the poisoned patient. This survey was developed in-house and utilized a Likert scale and was administered on Google Forms. In an effort to promote honest feedback, residents were made aware that submissions were anonymous and email information was not collected. Results Of the 22 participating residents (PGY1-3), 15 responded to our survey for a response rate of 68%. Overall, resident responses to the course were favorable. All participants except for one answered that they were “satisfied” or “very satisfied” with the course; the respondent who did not mark “satisfied” or “very satisfied” marked the option labeled “neutral.” Similarly, 93% (14/15) of respondents “agreed” or “strongly agreed” that they would recommend this course to a colleague, and 86% (13/15) “agreed” or “strongly agreed” that the course was a valuable use of their time. Resident responses also indicated an increased confidence in both the recognition of toxidromes and the management of poisoned patients. The majority of respondents (9/15) indicated that their perceived confidence in recognizing toxidromes improved after completion of the course; the remainder, except for one, remarked the same level of confidence before and after completing the course. The resident who had a decline in their confidence said they were “confident” in recognizing toxidromes prior to the course and “somewhat confident” after the course. Unsurprisingly, perceived confidence in the medical management of toxicology patients improved for 87% (13/15) of respondents after having taken the course, with 2 respondents noting the same level of confidence before and after taking the course. Lastly, multiple residents wrote in the free-response section that the toxicology rotation had been directly helpful to them when managing various toxidromes with real cases in the emergency department. For example, one response noted that they had since managed both a tricyclic antidepressant and a calcium channel blocker overdose, which they felt more comfortable with after completing the course. Another resident wrote about the experience of having a pediatric patient suffering from an ingestion of both acetaminophen and aspirin who was placed on a bicarbonate drip. Discussion This blended synchronous and asynchronous approach to a toxicology course was a success with the residents. Based on our survey responses, the majority of the residents felt this was a valuable educational experience. Many of the residents commented on times after the course where they were directly able to apply the knowledge learned from the modules, which was also encouraging. While COVID limitations kept our synchronous aspects virtual, these were also successful with the residents. While we had initially used oral boards style cases for the simulation session, we had found that engagement with learners during these sessions was not as high as we had hoped. We subsequently switched to using the virtual simulation platform Full Code.8 The learners seemed to enjoy these cases much more with having more visual stimulus during the cases. It was also less work on the part of the faculty to have pre-written toxicology cases to use and lab values/imaging results a click away. However, for institutions without a Full Code subscription, oral boards style cases or in person simulation would be a worthwhile alternative. Additionally, video conference sessions with our toxicology faculty members were helpful for the residents to go over the information they had learned in a question-and-answer format. Regarding the synchronous aspect of the course, having written the modules ahead of time, it was very easy to upload into an LMS. We particularly found Articulate Rise7 to be helpful as an LMS, especially with integrating some interactive elements into each module. However, this could easily be adapted into any LMS your institution prefers, or even into slideshow software. Topics General approach to poisoned patient, gastric decontamination, dialysis in toxicology, acetaminophen overdose (od), salicylate od, carbon monoxide poisoning, pediatric toxicology considerations, alcohol withdrawal, toxic alcohols, beta blocker od, calcium channel blocker od, tca od, serotonin syndrome, opiate od, body packers vs stuffers, marijuana, synthetic cannabinoids, gamma hydroxybutyric acid (ghb) od; cocaine toxicity, inhalant abuse, spider envenomations, snake envenomations, marine envenomations, mushroom toxicities, organophosphate poisoning.


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Lastly, multiple residents wrote in the free-response section that the toxicology rotation had been directly helpful to them when managing various toxidromes with real cases in the emergency department. For example, one response noted that they had since managed both a tricyclic antidepressant and a calcium channel blocker overdose, which they felt more comfortable with after completing the course. Another resident wrote about the experience of having a pediatric patient suffering from an ingestion of both acetaminophen and aspirin who was placed on a bicarbonate drip.
Discussion: This blended synchronous and asynchronous approach to a toxicology course was a success with the residents. Based on our survey responses, the majority of the residents felt this was a valuable educational experience. Many of the residents commented on times after the course where they were directly able to apply the knowledge learned from the modules, which was also encouraging. While COVID limitations kept our synchronous aspects virtual, these were also successful with the residents. While we had initially used oral boards style cases for the simulation session, we had found that engagement with learners during these sessions was not as high as we had hoped. We subsequently switched to using the virtual simulation platform Full Code. 8 The learners seemed to enjoy these cases much more with having more visual stimulus during the cases. It was also less work on the part of the faculty to have pre-written toxicology cases to use and lab values/imaging results a click away. However, for institutions without a Full Code subscription, oral boards style cases or in person simulation would be a worthwhile alternative. Additionally, video conference sessions with our toxicology faculty members were helpful for the residents to go over the information they had learned in a question-and-answer format.
Regarding the synchronous aspect of the course, having written the modules ahead of time, it was very easy to upload into an LMS. We particularly found Articulate Rise 7 to be helpful as an LMS, especially with integrating some interactive elements into each module. However, this could easily be adapted into any LMS your institution prefers, or even into slideshow software.
Topics: General approach to poisoned patient, gastric decontamination, dialysis in toxicology, acetaminophen overdose (od), salicylate od, carbon monoxide poisoning, pediatric toxicology considerations, alcohol withdrawal, toxic alcohols, beta blocker od, calcium channel blocker od, tca od, serotonin syndrome, opiate od, body packers vs stuffers, marijuana, synthetic cannabinoids, gamma hydroxybutyric acid (ghb) od; cocaine toxicity, inhalant abuse, spider envenomations, snake envenomations, marine envenomations, mushroom toxicities, organophosphate poisoning. Here we propose a one-week, blended asynchronous and synchronous rotation in toxicology that will give learners a foundation in important core toxicology concepts emergency medicine residents can implement on shift in the Emergency Department. This was a required PGY 1 rotation, but was available to residents of other years as well as an elective. Using a cognitivist framework for this approach, residents spend time on the asynchronous modules, and then have the ability to link the concepts learned online to scenarios proposed during synchronous activities with faculty. We hope this will lead to improved patient care since residents will have a deeper understanding of how to manage the poisoned patient.

Goals of the curriculum:
To introduce EM residents to core toxicology concepts, and to reinforce toxicology principles through a multimodal approach that leads to increased confidence in the management of poisoned patients on shift.

Objectives of the curriculum:
Module objectives separated by each day of the rotation

Results and tips for successful implementation:
In total, 22 residents completed the previously described toxicology curriculum between July 2020-July 2021. Due to social distancing guidelines of the coronavirus pandemic, the entire curriculum was administered virtually; however, the synchronous portions of this curriculum could likely be easily  adapted to in-person learning as well. Satisfaction with the course as well as perceived confidence in medical management of toxicology patients was assessed using a survey distributed to residents after completion of the course.
Of the 22 participating residents (PGY1-3), 15 responded to our survey for a response rate of 68%. Overall, resident responses to the course were favorable. All participants except for one answered that they were "satisfied" or "very satisfied" with the course; the respondent who did not mark "satisfied" or "very satisfied," marked the option labeled "neutral." Similarly, 93% (14/15) of respondents "agreed" or "strongly agreed" that they would recommend this course to a colleague, and 86% (13/15) "agreed" or "strongly agreed" that the course was a valuable use of their time (table 1).
Resident responses also indicated an increased confidence in both the recognition of toxidromes and the management of poisoned patients. The majority of respondents (9/15) indicated that their perceived confidence in recognizing toxidromes improved after completion of the course; the remainder, except for one, remarked the same level of confidence before and after completing the course. The resident who had a decline in confidence was "confident" in recognizing toxidromes prior to the course and "somewhat confident" after the course. Unsurprisingly, perceived confidence in the medical management of toxicology patients improved for 87% (13/15) of respondents after having taken the course, with 2 respondents noting the same level of confidence before and after taking the course.
Lastly, multiple residents wrote in the free-response section that the toxicology rotation had been directly helpful to them when managing various toxidromes with real cases in the emergency department. For example, one response noted that they had since managed both a tricyclic antidepressant and a calcium channel blocker overdose, which they felt more comfortable with after completing the course. Another resident wrote about the experience of having a pediatric patient suffering from an ingestion of both acetaminophen and aspirin who was placed on a bicarbonate drip.
This blended synchronous and asynchronous approach to a toxicology course was a success with the residents. Based on our survey responses, the majority of the residents felt this was a valuable educational experience. Many of the residents commented on times after the course where they were directly able to apply the knowledge learned from the modules, which was also encouraging. While COVID limitations kept our synchronous aspects virtual, these were also successful with the residents. While we had initially used oral boards style cases for the simulation session, we had found that engagement with learners during these sessions was not as high as we had hoped. We subsequently switched to using the virtual simulation platform Full Code. 8 The learners seemed to enjoy these cases much more with having more visual stimulus during the cases. It was also less work on the part of the faculty to have prewritten toxicology cases to use and lab values/imaging results a click away. However, for institutions without a Full Code subscription, oral boards style cases or in-person simulation would be a worthwhile alternative. Additionally, video conference sessions with our toxicology faculty members were helpful for the residents to go over the information they had learned in a question-and-answer format.
Regarding the synchronous aspect of the course, having written the modules ahead of time, it was very easy to upload into an LMS. We particularly found Articulate Rise 7 to be helpful as an LMS, especially with integrating some interactive elements into each module. However, this could easily be adapted into any LMS your institution prefers, or even into slideshow software.

Facilitator Instructions:
What worked best at our institution was to delegate a faculty member/fellow to be available during the week to answer questions as they came up for the residents as they were reviewing the modules. The same facilitator would be available on Wednesdays to either run Full Code simulations, or if your institution does not have access, "oral board" style cases or full simulations. Some alternatives have been listed below. On Fridays there was a Q and A session with our staff toxicologist, and we have made his slides available for your use should you choose to use them. They are also linked below.

Evaluation and Feedback:
Initially simulations were done virtually on a video conferencing platform as an oral boards style case. However, residents had commented that this was not as engaging as an in-person simulation case would be. We transitioned to using Full-Code, 8 an online simulation platform to help increase engagement. This was met with much more positive feedback. 8. You are evaluating a patient with history of hypertension who is found to be profoundly hypotensive and bradycardic after ingestion of an unknown substance. You perform standard resuscitation with IV fluids and have started vasopressors without improvement. What medication should you consider giving to increase inotropy? (free response) Answer: Acceptable responses are high dose insulin, HDI (hexamethylene diisocyanate), insulin 9. Despite your best efforts, your patient who was presumed to overdose on calcium channel blockers is getting worse, and you are concerned they will imminently go into cardiac arrest. What is a "last ditch" medication you can try to save the patient? (free response) Answer: lipid emulsion therapy, intralipid. Thursday Quiz Answers 1. A patient is dropped off by family in your ambulance bay. They state they found the patient unresponsive in their bathroom. They know the patient has a history of drug use, but they aren't sure what they use. You note the patient is significantly hypoxic to the 70's on room air and is only breathing at a rate of 6 bpm. What medicine should you reach for while preparing for a potential intubation? (free response)

2.
A patient is brought in for change in mental status. Was found by family members in his room completely disoriented. They did find several foil packets next to him that they say he sometimes gets from the corner store. They are labeled as incense not for human consumption. His urine drug screen is negative. What do you suspect caused this presentation? a. Marijuana b. GHB (gamma-Hydroxybutyric acid) c. Synthetic Cannabinoids d. Heroin 3. A patient presents to the ER for altered mental status. He was hanging out with his friends when they thought he fell asleep, but they were unable to wake him up. They state they drank a few beers playing video games today but deny any other drug use. They say he is very healthy and is constantly at the gym and don't think he has any medical problems. On your evaluation, he is unresponsive with severe respiratory depression. Naloxone does not help. He has no gag reflex on exam. You intubate him. The ICU wants to know what you suspect is going on; what drug do you suspect? (free response) Answer: GHB (Gamma Hydroxybutyrate). 4. You have been monitoring a patient in the ER for cocaine intoxication. The nurse calls you over to reevaluate the patient. He has become increasingly more agitated, diaphoretic and now with increasing tachycardia. You obtain the following EKG. What is another drug that can cause an EKG like this? (free response)